Healthcare Provider Details

I. General information

NPI: 1699957415
Provider Name (Legal Business Name): 464 MAIN STREET OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 10/23/2020
Certification Date: 10/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 MAIN ST
AGAWAM MA
01001-1826
US

IV. Provider business mailing address

101 E STATE ST
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 412-786-8000
  • Fax: 413-789-1099
Mailing address:
  • Phone: 610-925-4436
  • Fax: 610-925-4351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0875
License Number StateMA

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: ASST SECRETARY
Credential:
Phone: 505-468-4742